This POTD will be regarding sexual assault forensic examiner (SAFE) exams. Keep in mind that these patients have obviously just undergone a traumatic event. However, also consider that the ED course and examination in itself can also add onto this trauma, and so there are several steps we should undertake to mitigate this as much as we can.
Conduct interviews in a private setting. If available, please make use of a private room, such as an OBGYN room.
In addition to placing a SAFE consult, also consult a social work.
Even if a patient does not want a forensic examination performed, SAFE consults are useful in providing resources to patients, including resources for safe shelters, resources for applying to the state victim’s compensation fund, and mental wellness helplines.
When using translators, consider using audio-only translation or facing the video away from the patient, especially during the examination itself, to respect patient privacy.
General medical workup:
If the patient has not changed clothes, do not change the patient into a hospital gown.
All patients should be offered HIV PEP, STI prophylaxis, and pregnancy prophylaxis +/- pregnancy testing per patient preferences.
HIV PEP courses are 28 days. The Office of Victim Services funds the emergency department for a 7-day starter pack to take home. The patient will need to follow up with PMD or ID clinic for the rest.
STI testing may be considered if the patient asks for it, although will not have forensic value in the timeframe most patients show up after an assault. You should just treat empirically.
On physical exams, extra attention should be placed on signs of physical trauma, with imaging as indicated by history and exam.
Pediatric patients
All suspected sexual assaults or abuse of patients younger than 18 years are required to be reported to child protective services. All hospital staff are legally considered to be mandated reporters.
CPS reports may be made at 1-800-342-3720.
A written reports needs to be filed within 48 hours of calling. Forms are found at https://ocfs.ny.gov/programs/cps/
Mature minors may choose to consent or not consent to a forensic exam without parental involvement.
Financial resources for patients
Victims of sexual assault can apply to the Office of Victim Services for out-of-pocket expenses not covered by insurance.
Examples of covered expenses are listed in the application form, but include lost wages, medical/ambulance costs, crime scene cleanup, purchasing a security system.
An English form is included in the SAFE exam kit, part A. Other languages may be printed from https://ovs.ny.gov/victim-compensation
How to perform a SAFE examination and Sexual Offence Evidence Collection Kits (SOECK). Please allot up to 4 hours for this.
A powerpoint of these instructions, with pictures may be found at https://apps.criminaljustice.ny.gov/ofpa/pdfdocs/Sexual%20Offense%20Evidence%20Collection%20Kit%20Training%201-2023.pdf.
Two different kits.
Once the kit is opened, the chain of custody begins and you should not leave the kit until it has been sealed, signed, and handed off to the next custodian.
SOECK part A (larger kit)
Contains consent forms, victim compensation application form, STI/HIV prophylaxis educational forms, and an evidence seal.
Contains envelopes and swabs for specimen samples.
SOECK part B
Supplementary kit containing x2 blood tubes and x1 urine cup for suspected drug facilitated sexual assault.
Requires completion of part A in addition to part B. Should not be collected on its own.
Requires its own consent form.
Items to obtain prior to exam, that are not included in kits.
x4 pages of patient labels with patient full name and DOB
Paper bags if collecting patient clothes.
Exam table paper (i.e. the paper found on the peds ED triage bed)
Clean bed sheets and blankets
Disposable cups
Consider bringing an extra kit in case you make a mistake and need to recollect a sample.
Determine and obtain consent for the following:
An English consent form is available in each kit. Consent forms in other languages may be printed from https://apps.criminaljustice.ny.gov/evidencekit.htmCollection of evidence.
Samples have the highest forensic value when collected within 120 hours after incident, but examiner discretion may be used for collections after this window.
Collection of photographs
We do not regularly collect photographs as part of our exam, so this part is not relevant for us.
Release of evidence to the police.
If the patient does not want to release evidence, it will be held for 20 years in either our hospital forensic storage room or a storage facility at the Office of Victim Services, which is not a law enforcement agency2. The patient may later elect to release the kit or destroy the kit.
Supplemental information form
Information to obtain from the patient that is relevant for the forensic laboratory.
Evidence collection
There should always be a chaperone in the room.
Part A contains 12 envelopes, each labelled with instructions for obtaining specimens (See example below). They are ordered from least invasive to most invasive samples.
For each step:
The patient may consent or decline each step and skip to the next step.
Change gloves between each step.
Attached a patient label to each envelope, fill out any relevant fields. Date & timestamp & initial each envelope.
Part A
Step 1 – Trace evidence and debris
Step 2 – Underwear
Step 3 – Clothing
If they release their clothes for collection. You can ask social work or mental health workers for replacement clothes.
This step requires a separate paper bag for each article of clothing (not included in kit)
Step 4 – Oral swabs
Step 5 – Buccal swabs
This step serves as a reference sample for the patient’s own DNA and should be recommended to all patients.
Step 6 – Fingernail swabs
Step 7 – External dried secretions and bitemarks
Step 8 – Pubic Hair Combing
Step 9 – Perianal/Anal Sample
Step 10 – Vulvar or Penile Swab
Step 11 – Vaginal/Cervical Swab
Step 12 – Tampon/Pad/Liner Collection
Part B (if applicable)
Collect x2 blood samples, x1 urine sample. Label and seal each sample with the provided seal.
Attach patient label to box. Seal all envelopes. Make copies of relevant forms (each form includes at bottom how many copies to make, where each copy goes)
Seal and initial each kit with the provided seal.
Storage or release of kit
If police are at bedside and patient consents to release evidence, you may release the completed kit to the police office and have them sign off on the chain of custody on the box.
Otherwise your hospital should have a secured and temperature controlled storage facility for storage pending transport to the storage facility at the Office of Victim Services.